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Managing Behavior and Eliminating Harm: Moving Towards a Just and Safe Culture

Eric I. Rosenberg, M.D.

Associate Professor & Division Chief, Internal Medicine

University Of Florida

Patient Safety focuses on protecting patients from harm by learning methods of preventing adverse avoidable events due to latent, often unidentified flaws in complex medical care systems. Clinicians are and should be held accountable for improving care systems, but since 95% of medical harm involves competent, conscientious people working within complex healthcare environments, punishing individuals for their unintended mistakes will not protect future patients from harm — and does not address the fundamental system issues that typically contribute to a mistake. Fear of prosecution or job loss inhibits reporting of “near misses”; errors that could have resulted in patient harm if not for serendipitous circumstances. It is these reports that have lead to the greatest gains in patient safety. Employees who work in punitive workplace cultures will be understandably reluctant to come forward and report errors for fear of retribution. Organizations that are recognized for safety and reliability expect imperfection and dedicate a great deal of effort towards identifying and solving problems of latent error. “Just Culture” is a system of management championed by David Marx, Lucian Leape and other leaders within patient safety that focuses on management of human behavioral choices that are an inevitable part of working within a complex workplace where professionals exercise judgment as an expected part of their professional duties and where system design and workflow can result in behaviors that lead to increased risk of error and adverse events.

In a Just Culture, employees know that the constant goal is decreasing harm to the next patient and are comfortable sharing lessons learned from personal errors without fear of retribution. This not a “blame-free” approach to adverse patient safety events; rather, as David Marx notes, “society rightly requires that some actions warrant disciplinary or enforcement action. [Just Culture balances] the need to learn from our mistakes and the need to take disciplinary action….” [David Marx, Patient Safety and the “Just Culture:” A Primer for Health Care Executives; April 17, 2001]

There are 3 main behaviors that are predictable within the clinical care environment: human error, defined as “inadvertently doing other than what should have been done” and comprising slips, lapses and mistakes; at-risk behavior, defined as acting without recognizing risk or mistakenly believing that risk is justified under the circumstances; and finally, reckless behavior, consciously acting with no regard for the “substantial and unjustifiable risk” that one is taking. [Outcome Engenuity, The Just Culture Community] This latter form of behavior is extremely rare in healthcare environments. At-Risk behavior is the most common and problematic phenomenon associated with preventable adverse patient safety events and arises from predictable changes in the way we perceive risk with experience and repetitive exposure to similar situations.

Under production pressure, communication and team work break down while the system continues to strive for efficiency — to do more with less time. Humans engage in “short cuts” such as multi-tasking, skipping portions of checklists and relying on memory, and overriding safety alerts generated by computerized medication order entry systems because they are perceived as “false alarms.” In time, as these short cuts pay off in time saved, humans perceive a fading perception of risk when no negative consequences have occurred. This further reinforces risk taking behavior.

Regardless of whether a serious adverse outcome occurs as a consequence of adverse behavior, Just Culture holds that this type of behavior should be managed through coaching employees in the implications of these practices through creation of greater situational awareness– and that the management system can help reduce or eliminate these behaviors through removing the hidden incentives to engage in these practices and shift towards healthier behavior choices. Punishing or terminating an employee who had no intention of causing harm will not create a safer clinical environment for patients being cared for by another substitute employee within the same care system.

Ultimately, the promise of Just Culture is that staff and management expectations change to where human imperfection is expected and the focus of the patient care system shifts towards a proactive search for novel risks and hazards in order to refine and continually work towards safer medical care. Through fair and just standards of accountability, medical care personnel are empowered to make safer choices. The reward of a Just Culture is an engaged workforce that discusses adverse events openly and turns them into opportunities to improve healthcare.